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V626 C ONDITION STATEMENT  The dialysis facility must develop, implement, maintain and evaluate an effective, data driven, quality assessment and performance improvement program with participation by the professional members of the interdisciplinary team.

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V627 C ONDITION STATEMENT  The dialysis facility must maintain and demonstrate evidence of its quality improvement and performance improvement program for review by CMS

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V638 M ONITORING I MPROVEMENT The facility must:  Continuously monitor its performance  Take actions that result in performance  improvement  Track to assure improvements are sustained over time

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W HAT IS QAPI?  Quality Assessment Performance Improvement (QAPI)  Under QAPI, the focus is on assessing outcomes to see whether good results are being achieved.  More proactive approach to quality and to improvement.

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QAPI E LEMENTS  The professional members of the facility’s interdisciplinary team (IDT), which must participate in QAPI activities, consist of a physician, registered nurse, masters-prepared social worker, and registered dietitian.

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QAPI E LEMENTS  There must be an operationalized, written plan describing the QAPI program scope including:  Objectives  Organization  Responsibilities of all participants  Procedures for overseeing the effectiveness of monitoring, assessing, and problem-solving activities.

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QAPI E LEMENTS  Within the facilities QAPI program, facilities are expected to use the community-accepted standards and values associated with clinical outcomes as referenced on the MAT (measures assessment tool).

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QAPI E LEMENTS  If a facility has areas of that do not meet target levels (per MAT) or areas where the facility performance is below average (per data reports), the facility is expected to take action toward improving those outcomes.

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QAPI E LEMENTS  QAPI requires the use of aggregate patient data to evaluate the facility patient outcomes.  Hemodialysis and peritoneal dialysis patients should be reviewed separately since factors affecting their clinical outcomes may be different; both groups of patients must be reviewed on an ongoing basis.

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H OW TO DO IT …  Identify the problem  Review collective patient data;  Look at trends Steady improvement or stable outcomes Abrupt or steady decline in outcomes  Identify any commonalities among patients who do not reach the minimum expected targets; One vehicle accident may not indicate you are a bad driver….. However…10 accidents a year may cause your insurance company to make some changes in your plan!

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T HEN WHAT ?  Work together – entire IDT  Write clear statement identifying problem  Use numerical “measurable” goal  Set specific time range to meet goal  Assure goal is obtainable within specified time range Use smaller goals in step by step fashion until ultimate goal is reached Example : GOAL: Reduce number of catheter patients to <10% by December 2010 Or …Reduce number of catheter patients by 2% each month

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A ND MORE  Identify Root Causes:  For Example: If a data report shows that the facility’s ranking for hemodialysis adequacy is below the expected average  Facility must demonstrate QAPI review of global factors that might affect adequacy  Brainstorming with IDT  Data/Spreadsheets to “measure” barriers

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D EVELOP A CTION AND I NTERVENTIONS  Focus on process  What process can you change or create that will have a positive impact?  Make actions barrier-specific How will changes impact the root cause?  Choose one or two actions which will have the greatest impact (Rapid cycle improvement)  Review available best practices Will they work in your facility?  Discuss how you will monitor new processes How will you know if changes are an improvement?

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C HANGE P ROCESSES Example:  Facility determines inadequate BFR’s are highest priority root cause for patients not achieving adequacy  Facility reviews current process and determines new process is needed NEW PROCESS >  Daily audit checksheet:  Nurse rounds after initiation of each shift to assure BFR and other prescription parameters are met  Allows action to be taken immediately rather than waiting for monthly lab review to reveal a problem